Severe hemorrhage during an incisional biopsy: a report of a case.

BACKGROUND: Surgical procedures under local anesthesia are routinely employed by the dentist and are susceptible to significant complications which demand immediate care from the dental professional. REPORT: This report presents a case of severe arterial hemorrhage during a simple removal of a lesion during an incisional biopsy. SUMMARY: In the event of severe arterial hemorrhage in a conventional dental office, manual compression for containing the hemorrhage and use of an adequate light source to correctly visualize the origin of the bleeding is recommended. If visible, the dental surgeon must attempt to perform vascular ligature or an occlusive suture. If the hemorrhage cannot be controlled after these measures, the patient must be transported to a hospital while continuing local compression during transit.

Effectiveness of Periapical Radiography Versus Cone Beam Computed Tomography with Different Kilovoltage Settings in the Detection of Chemically Created Peri-implant Bone Defects: An In Vitro Study.

PURPOSE: To determine the effectiveness of cone beam computed tomography (CBCT) images obtained with different kilovoltage settings compared with intraoral periapical photostimulable storage phosphor (PSP) plate images in the detection of chemically created peri-implant defects utilizing a bovine rib bone model in vitro. MATERIALS AND METHODS: After placing 80 implants in bovine ribs, peri-implant circumferential bone defects of different sizes were created with 70% perchloric acid. CBCT images (3D Accuitomo 170) were acquired at 90 and 75 kVp, and intraoral periapical images were acquired using a PSP system (Carestream KODAK, CS 7600). Using a 5-point Likert scale, two oral and maxillofacial radiologists (OMR) and two oral and maxillofacial surgeons (OMS) evaluated the likelihood of a bone defect being absent or present. The kappa statistic was used to compare observer agreement, and area under the curve values were compared using analysis of variance and the post hoc Tukey test. Significance was set at P ≤ .05. RESULTS: PSP reliability ranged from discordance to slight for small defects and fair to moderate for larger defects. For CBCT, OMRs had good agreement for defects using 90 kVp, and slight to fair using 75 kVp. Agreement for OMS observations was fair for 75 kVp, and varied from slight to good for 90 kVp. Small lesions were detected more effectively by CBCT than by PSP, and larger lesions were detected more effectively by CBCT at 90 kVp than by CBCT at 75 kVp or by PSP. CONCLUSION: CBCT imaging at 90 kVp was associated with a significantly higher rate of detection of both small and large chemically simulated bone defects than PSP or CBCT at 75 kVp. CBCT imaging at 75 kVp proved better than PSP for the detection of small defects.

Effect of Cone-Beam Computed Tomography Field of View and Acquisition Frame on the Detection of Chemically Simulated Peri-Implant Bone Loss In Vitro.

BACKGROUND: The aim of this study is to determine the influence of field of view (FOV) and number of acquisition projection images (frames) on the detection of chemically simulated peri-implant defects by cone-beam computed tomography (CBCT) using an in vitro bovine rib bone model. METHODS: Eighty implants were placed in bovine ribs in which small and large bone defects were created using 70% perchloric acid. CBCT images were acquired at three acquisition protocols: protocol 1 (FOV 4 × 4 cm, 0.08-mm voxel size, 1,009 frames [high fidelity]; protocol 2 (same as protocol 1 except 512 frames [standard]); and protocol 3 (FOV 14 × 5 cm, 0.25-mm voxel size; high fidelity). Two oral and maxillofacial radiologists (OMRs) and two oral and maxillofacial surgeons (OMSs) rated the presence or absence of bone defects on a five-point scale. κ and area under the curve (AUC) were calculated and compared using analysis of variance with post hoc Tukey test at P ≤ 0.05. RESULTS: Intra- and interobserver agreement for OMRs ranged from moderate to good and from slight to moderate for OMSs. For the detection of small lesions, protocol 1 (AUC 0.813 ± 0.045) provided higher detection rates than protocol 2 (AUC 0.703 ± 0.02) and protocol 3 (AUC 0.773 ± 0.55) [F(2,9) = 1.6377]. For larger defects, the trends were similar, with protocol 1 (AUC 0.852 ± 0.108) providing higher detection rates than protocol 2 (AUC 0.730 ± 0.045) and protocol 3 (AUC 0.783 ± 0.058) [F(2,9) = 1.9576]. CONCLUSION: Within the limits of this study, optimal detection of chemically simulated pericircumferential implant crestal bone defects is achieved at the least radiation detriment using the smallest FOV, the highest number of acquisition frames, and the smallest voxel.

Effect of field of view in the detection of chemically created peri-implant bone defects in bovine ribs using cone beam computed tomography: an in vitro study.

OBJECTIVES: To assess the accuracy of cone beam computed tomography (CBCT) using two fields of view (FOVs) in the diagnosis of peri-implant defects. STUDY DESIGN: Eighty implants were placed in bovine ribs, in which peri-implant bone defects of two sizes (T1 and T2) were simulated using 70% perchloric acid. CBCT images were acquired with the use of two FOV size settings of the i-CAT NG unit: 6 × 16 cm and 8 × 8 cm. One oral and maxillofacial surgeon (OMS) and two oral and maxillofacial radiologists (OMRs) evaluated the presence of defects, and their findings were compared with direct visual evaluation. The kappa (κ)-statistic, area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the examinations were calculated. AUC values were compared with the Student t test. RESULTS: The obtained κ-values indicated good intra- and interobserver agreement. A significant difference was found between T1 and T2 (P = .01) with regard to AUC values, and no significant difference was found between the different FOVs in both test groups (T1, P = .06; T2, P = .33). The sensitivity, specificity, PPV, and NPV of the examinations were higher for the OMRs than for the OMS involved in the study. CONCLUSIONS: The ability of CBCT to detect chemically created peri-implant bone defects was good, especially for larger defects (Group T2) but only for the observations of the OMRs. The observations of the OMS were less accurate. The two FOVs tested were appropriate to detect peri-implant bone defects.

Influence of cone-beam computed tomographic scan mode for detection of horizontal root fracture.

INTRODUCTION: The purpose of the present study was (1) to test the accuracy of a small-volume cone-beam computed tomographic (CBCT) device in detecting horizontal root fractures (HRFs) in teeth with and without an intracanal metallic post (IMP) and (2) to investigate the use of 2 different acquisition protocols of a CBCT device for HRF diagnosis. METHODS: Forty endodontically treated teeth with and without an IMP were examined using PreXion 3D CBCT scanner (Terarecon, San Mateo, CA) with a 5-cm high and 5-cm diameter cylinder at 0.10-mm voxel reconstruction. Two observers analyzed the samples to determine the presence and location of HRFs. RESULTS: Sensitivity values ranged from 0.40-0.80. The most favorable results were found for the samples with no IMP observed using the protocol of a higher number of x-ray projections (0.70-0.80). Accuracy in the groups with an IMP ranged from 75%-90% in the 1024 x-ray projection protocol (HI-HI group) versus 70%-85% for the same samples examined in the 512 x-ray projection protocol (HI-STD group). Intraobserver agreement ranged from relevant to perfect concordance for both protocols (HI-HI = Kappa: 0.60-1.00 and HI-STD = Kappa: 0.55-0.89). Interobserver agreement ranged from moderate to perfect concordance for both protocols (HI-HI = Kappa: 0.79-0.89 and HI-STD = Kappa: 0.42-0.76). CONCLUSIONS: Even though there are statistically significant differences for the protocol with the higher number of x-ray projections, we found high accuracy, sensitivity, sensibility, and intra- and interobserver agreement in detecting HRFs for both Prexion 3D protocols.

Accuracy and reliability of linear measurements using 3-dimensional computed tomographic imaging software for Le Fort I Osteotomy.

Our purpose was to compare the accuracy and reliability of linear measurements for Le Fort I osteotomy using volume rendering software. We studied 11 dried skulls and used cone-beam computed tomography (CT) to generate 3-dimensional images. Linear measurements were based on craniometric anatomical landmarks that were predefined as specifically used for Le Fort I osteotomy, and identified twice each by 2 radiologists, independently, using Dolphin imaging version 11.5.04.35. A third examiner then made physical measurements using digital calipers. There was a significant difference between Dolphin imaging and the gold standard, particularly in the pterygoid process. The largest difference was 1.85mm (LLpPtg L). The mean differences between the physical and the 3-dimensional linear measurements ranged from -0.01 to 1.12mm for examiner 1, and 0 to 1.85mm for examiner 2. Interexaminer analysis ranged from 0.51 to 0.93. Intraexaminer correlation coefficients ranged from 0.81 to 0.96 and 0.57 to 0.92, for examiners 1 and 2, respectively. We conclude that the Dolphin imaging should be used sparingly during Le Fort I osteotomy.

Detection of simulated incipient furcation involvement by CBCT: an in vitro study using pig mandibles.

The aim of the present study was to test the reproducibility, sensitivity, and specificity of cone-beam computed tomography (CBCT) in detecting incipient furcation involvement. Fifteen macerated pig mandibles, with intact second molar teeth and preserved adjacent cortical areas, were used. Simulated lesions were created in the furcation region of these teeth by applying 70% perchloric acid in up to four possible buccal/lingual sites in the right/left sides of each mandible. The mandibles were then submitted to a CBCT scan. Two blinded and calibrated experienced oral and maxillofacial radiologists interpreted the exams. Furcation involvement was also assessed in the regions without simulated lesions. CBCT showed high levels of accuracy, ranging from 78% to 88%. The variations in Kappa values for intra- and inter-observer agreement (0.41-0.59) were considered moderate. CBCT can be considered a reliable and accurate method for detecting incipient furcation involvement.

Use of large-volume cone-beam computed tomography in identification and localization of horizontal root fracture in the presence and absence of intracanal metallic post.

INTRODUCTION: The objective of the study was to evaluate the ability of large-volume cone-beam computed tomography (CBCT) to detect horizontal root fracture and to test the influence of a metallic post. METHODS: Through the examination of 40 teeth by large-volume CBCT (20-cm height and 15-cm diameter cylinder) at 0.2-mm voxel resolution, 2 observers analyzed the samples for the presence and localization of horizontal root fracture. RESULTS: The values of accuracy in the groups that had no metallic post ranged from 33%-68%, whereas for the samples with the metallic post, values showed a wide variation (38%-83%). Intraobserver agreement showed no statistically significant difference between the groups with/without metallic post; both ranged from very weak to weak (kappa, 0.09-0.369). CONCLUSIONS: The low accuracy and low intraobserver and interobserver agreement reflect the difficulty in performing an adequate diagnosis of horizontal root fractures through a large-volume CBCT by using a small voxel reconstruction.

Cleft lip and palate: recommendations for dental anesthetic procedure based on anatomic evidences.

Patients with cleft lip and palate usually present dental anomalies of number, shape, structure and position in the cleft area and the general dentist is frequently asked to restore or extract those teeth. Considering that several anatomic variations are expected in teeth adjacent to cleft areas and that knowledge of these variations by general dentists is required for optimal treatment, the objectives of this paper are: 1) to describe changes in the innervation pattern of anterior teeth and soft tissue caused by the presence of a cleft, 2) to describe a local anesthetic procedure in unilateral and bilateral clefts, and 3) to provide recommendations to improve anesthetic procedures in patients with cleft lip and palate. The cases of 2 patients are presented: one with complete unilateral cleft lip and palate, and the other with complete bilateral cleft lip and palate. The patients underwent local anesthesia in the cleft area in order to extract teeth with poor bone support. The modified anesthetic procedure, respecting the altered course of nerves in the cleft maxilla and soft tissue alterations at the cleft site, was accomplished successfully and the tooth extraction was performed with no pain to the patients. General dentists should be aware of the anatomic variations in nerve courses in the cleft area to offer high quality treatment to patients with cleft lip and palate.

Detection of horizontal root fracture with small-volume cone-beam computed tomography in the presence and absence of intracanal metallic post.

INTRODUCTION: The aim of the present study was to test the accuracy of small-volume cone-beam computed tomography (CBCT) scanning in the detection of horizontal root fractures and to assess the influence of a metallic post. METHODS: Forty teeth were divided into four groups based on the presence of metallic posts and horizontal root fracture. The teeth were examined by small-volume CBCT scanning at 0.2-mm voxel resolution. Three observers analyzed the samples for the presence of a horizontal root fracture. Sensitivity and specificity were calculated. RESULTS: High values for accuracy (73%-88%) were obtained in the groups without a metallic post, and statistically significant differences were found when the group with a metallic post has been observed (55%-70%). Intraobserver agreement also showed statistically significant differences in the groups with a metallic post. CONCLUSIONS: Small-volume CBCT scanning showed high accuracy in detecting horizontal root fracture without a metallic post. However, the presence of a metallic post significantly reduced the specificity and sensitivity of this examination.

Comparison between multislice and cone-beam computerized tomography in the volumetric assessment of cleft palate.

The aim of this study was to determine the applicability of multislice and cone-beam computerized tomography (CT) in the assessment of bone defects in patients with oral clefts. Bone defects were produced in 9 dry skulls to mimic oral clefts. All defects were modeled with wax. The skulls were submitted to multislice and cone-beam CT. Subsequently, physical measurements were obtained by the Archimedes principle of water displacement of wax models. The results demonstrated that multislice and cone-beam CT showed a high efficiency rate and were considered to be effective for volumetric assessment of bone defects. It was also observed that both CT modalities showed excellent results with high reliability in the study of the volume of bone defects, with no difference in performance between them. The clinical applicability of our research has shown these CT modalities to be immediate and direct, and they is important for the diagnosis and therapeutic process of patients with oral cleft.

Comparison between cone-beam and multislice computed tomography for identification of simulated bone lesions.

There are many studies that compare the accuracy of multislice (MSCT) and cone beam (CBCT) computed tomography for evaluations in the maxillofacial region. However, further studies comparing both acquisition techniques for the evaluation of simulated mandibular bone lesions are needed. The aim of this study was to compare the accuracy of MSCT and CBCT in the diagnosis of simulated mandibular bone lesions by means of cross sectional images and axial/MPR slices. Lesions with different dimensions, shape and locularity were produced in 15 dry mandibles. The images were obtained following the cross sectional and axial/MPR (Multiplanar Reconstruction) imaging protocols and were interpreted independently. CBCT and MSCT showed similar results in depicting the percentage of cortical bone involvement, with great sensitivity and specificity (p < 0.005). There were no significant intra- or inter-examiner differences between axial/MPR images and cross sectional images with regard to sensitivity and specificity. CBCT showed results similar to those of MSCT for the identification of the number of simulated bone lesions. Cross sectional slices and axial/MPR images presented high accuracy, proving useful for bone lesion diagnosis.

Access to the frontal sinus and zygomatico frontal suture through the supratarsal fold.

Precise repositioning of a fractured zygoma is difficult. The traditional approach is through an eyebrow incision, but it can produce a scar that causes aesthetic and psychological problems for the patient. We describe the supratarsal fold approach to expose the frontozygomatic suture and to reduce small displacements of frontal sinus anterior wall; it gives good access and excellent aesthetic results.

Detection of simulated incipient furcation involvement by CBCT: an in vitro study using pig mandibles

The aim of the present study was to test the reproducibility, sensitivity, and specificity of cone-beam computed tomography (CBCT) in detecting incipient furcation involvement. Fifteen macerated pig mandibles, with intact second molar teeth and preserved adjacent cortical areas, were used. Simulated lesions were created in the furcation region of these teeth by applying 70% perchloric acid in up to four possible buccal/lingual sites in the right/left sides of each mandible. The mandibles were then submitted to a CBCT scan. Two blinded and calibrated experienced oral and maxillofacial radiologists interpreted the exams. Furcation involvement was also assessed in the regions without simulated lesions. CBCT showed high levels of accuracy, ranging from 78% to 88%. The variations in Kappa values for intra- and inter-observer agreement (0.41-0.59) were considered moderate. CBCT can be considered a reliable and accurate method for detecting incipient furcation involvement.

Cleft lip and palate: recommendations for dental anesthetic procedure based on anatomic evidences

Patients with cleft lip and palate usually present dental anomalies of number, shape, structure and position in the cleft area and the general dentist is frequently asked to restore or extract those teeth. Considering that several anatomic variations are expected in teeth adjacent to cleft areas and that knowledge of these variations by general dentists is required for optimal treatment, the objectives of this paper are: 1) to describe changes in the innervation pattern of anterior teeth and soft tissue caused by the presence of a cleft, 2) to describe a local anesthetic procedure in unilateral and bilateral clefts, and 3) to provide recommendations to improve anesthetic procedures in patients with cleft lip and palate. The cases of 2 patients are presented: one with complete unilateral cleft lip and palate, and the other with complete bilateral cleft lip and palate. The patients underwent local anesthesia in the cleft area in order to extract teeth with poor bone support. The modified anesthetic procedure, respecting the altered course of nerves in the cleft maxilla and soft tissue alterations at the cleft site, was accomplished successfully and the tooth extraction was performed with no pain to the patients. General dentists should be aware of the anatomic variations in nerve courses in the cleft area to offer high quality treatment to patients with cleft lip and palate.

Study of dimensional alterations of the orbit following loss of the eye.

PURPOSE: This study aimed to assess the dimensional alterations in the anterior region of the orbit after enucleation or evisceration. MATERIALS AND METHODS: Analysis of orbital areas and perimeters of 17 patients with unilateral removal of the ocular bulb was performed, and posteroanterior radiographic examination was carried out by a single specialist, who had been previously calibrated. RESULTS: Data obtained from measurements confirmed the clinically observed facial asymmetry. CONCLUSION: The observation of asymmetry in the anterior orbital area, confirmed by our results, indicates early treatment to prevent orbital disturbances and will aid in the planning of prosthetic rehabilitation.

Comparison between cone-beam and multislice computed tomography for identification of simulated bone lesions

There are many studies that compare the accuracy of multislice (MSCT) and cone beam (CBCT) computed tomography for evaluations in the maxillofacial region. However, further studies comparing both acquisition techniques for the evaluation of simulated mandibular bone lesions are needed. The aim of this study was to compare the accuracy of MSCT and CBCT in the diagnosis of simulated mandibular bone lesions by means of cross sectional images and axial/MPR slices. Lesions with different dimensions, shape and locularity were produced in 15 dry mandibles. The images were obtained following the cross sectional and axial/MPR (Multiplanar Reconstruction) imaging protocols and were interpreted independently. CBCT and MSCT showed similar results in depicting the percentage of cortical bone involvement, with great sensitivity and specificity (p < 0.005). There were no significant intra- or inter-examiner differences between axial/MPR images and cross sectional images with regard to sensitivity and specificity. CBCT showed results similar to those of MSCT for the identification of the number of simulated bone lesions. Cross sectional slices and axial/MPR images presented high accuracy, proving useful for bone lesion diagnosis.

CT interpretation of craniofacial anomalies: a comparative analysis by undergraduate dental students.

The aim of this study was to evaluate the accuracy and reproducibility of computed tomography (CT) image interpretation made in axial slices (2D-CT) and 3D reconstructed images (3D-CT) of patients with craniofacial anomalies. The analyses were made by undergraduate dental students, and compared with the diagnoses considered upon surgical intervention. Computed tomography of 43 patients were analyzed independently by three calibrated examiners (undergraduate students) with, respectively, one, two, and three semesters of experience in craniofacial CT training and interpretation. The analysis of 2D-CT and 3D-CT images were performed at distinct times using an independent workstation associated with a specific computer graphics software for volumetric images. The analysis of inter-examiner agreement and of the agreement between observers and the gold standard was performed using the Kappa test. The accuracy evaluation presented a progressively higher value for examiners with progressively broader experience in 2D-CT and 3D-CT image interpretation. 3D-CT analyses allowed a higher inter-examiner agreement (1 - 0.896) than 2D-CT analyses (1 - 0.614). 3D-CT was considered more precise and accurate than 2D-CT for all students' evaluations. The reproducibility and accuracy varied according to the experience in CT interpretation, and the most experienced student achieved results closer to the gold standard.

Diagnóstico de fraturas do terço médio facial: Indicação da técnica radiográfica occipto-mental (Waters) com máxima abertura de boca / Midface fracture diagnosis: indication of the occipitomental radiograph (Waters? view) with maximum mouth opening

Objetivo: Este trabalho analisou as vantagens e limitações da técnica radiográfica occiptomental (Waters) com máxima abertura de boca para o diagnóstico de fraturas do terço médio da face. Descrição do caso: O diagnóstico de fraturas faciais é auxiliado por técnicas radiográficas após realização de exame clínico criterioso. Classicamente, no pronto-atendimento solicitam-se 4 a 5 incidências, que aumentam o tempo de atendimento, os custos e a dose total de radiação recebida pelo paciente. A técnica occipto-mental (Waters) originalmente descrita para seios de face permite avaliação da cavidade orbitária, processo alveolar, crista e corpo do zigomático. Recentemente, a literatura tem sugerido a técnica de Waters como única incidência a ser solicitada no exame inicial do paciente, substituindo as incidências descritas anteriormente; com isso, haveria a diminuição da dose de radiação, no tempo de atendimento ao paciente e nos custos por radiografia sem prejudicar o diagnóstico das fraturas do terço médio facial. Apesar de ser indicada como incidência única, a técnica de Waters gera sobreposição óssea na região inferior do terço médio, impedindo uma perfeita visualização desta porção. Conclusão: Indicamos uma variante desta técnica, com máxima abertura de boca, pois possibilita a avaliação da porção inferior do terço médio sem sobreposição, sendo uma das poucas incidências convencionais que permite a visualização de fraturas tranversais do palato.

Purpose: This paper reviews the advantages and limitations of the occipitomental view (Waters) with maximum mouth opening for the diagnosis of midfacial fractures. Case description: The diagnosis of facial fractures is supported by radiographic techniques after an accurate clinical exam. In Accident & Emergency departments (A&E) four or five radiographs often are taken, which increases clinical time, costs, and radiation exposure. The most used radiographic view is the occipitomental view (OM), which was first described for facial sinus and allows evaluation of the orbital floor, zigomatic processes, buttress, and arches. Recent literature has suggested the use of the OM view as a single radiographic exam for initial patient screening, reducing radiation exposure, clinical time, and costs without compromising the identification of midfacial fractures. However, the Water's technique generates bone image superimposition at the inferior midface, preventing perfect visualization of this region. Conclusion: We indicate a modified Water's view taken with maximum mouth opening, which allows proper evaluation of the inferior midface and the visualization of transversal palatal fractures.